Resuscitation 81 (2010) 1101–1104 Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Clinical paper Biphasic DC shock cardioverting doses for paediatric atrial dysrhythmias  James Tibballs a,∗ , Bradley Carter b , Nicholas J. Kiraly b , Philip Ragg c , Michael Clifford c a Intensive Care Unit, Royal Children’s Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia b Clinical Technology, Royal Children’s Hospital, Melbourne, Australia c Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Melbourne, Australia article info Article history: Received 5 January 2010 Received in revised form 23 April 2010 Accepted 27 April 2010 Keywords: DC shock Dose Cardioversion Biphasic Dysrhythmia Atrial Children abstract Objective: To determine cardioversion doses of biphasic DC shock for paediatric atrial dysrhythmias. Design: Prospective recording of energy, pre-shock and post-shock rhythms. Setting: Paediatric hospital. Patients: Shockable atrial dysrhythmias. Main results: Forty episodes of atrial dysrhythmias among 25 children (mean age 6.8 ± 7.1 years, mean weight 28.2 ± 28.5 kg) were treated with external shock. The first shock converted the dysrhythmia to sinus rhythm in 25 episodes. Cardioversion occurred in 2 of 8 (25%) episodes with a dose of <0.5 J/kg, 14 of 16 (88%) with a dose of 0.5–1.0 J/kg and 9 of 16 (56%) with a dose of >1.0 J/kg (p = 0.01, Fisher’s exact test). Ten of 15 initially non-responsive episodes were cardioverted with additional shocks at 1.1 ± 0.6 J/kg (range 0.5–2.1 J/kg). Of the remaining 5 unresponsive episodes, 2 of ventricular fibrillation (induced by unsynchronized shock) were successfully defibrillated, and 3 were managed with cardiopul- monary bypass. Among 11 additional children (mean age 4.3 ± 6.8 years, mean weight 18.1 ± 22.0 kg), 18 episodes of atrial dysrhythmias were treated with internal shock which successfully cardioverted all episodes with one or more shocks at 0.4 ± 0.2 J/kg. Conclusions: In rounded doses, recommended initial external cardioversion doses are 0.5–1.0 J/kg and subsequently up to 2 J/kg, internal cardioversion doses are 0.5 J/kg. © 2010 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Little scientific evidence is available to guide clinicians in their selection of dose of biphasic direct current (DC) for shockable atrial cardiac dysrhythmias in teenage children 1,2 and none is available for infants and small children. Although clinical guidelines recom- mend doses, 3–5 the ideal dose which restores sinus rhythm (SR) with a single shock without damaging the myocardium is unknown. We aimed to determine the initial and subsequent doses of biphasic energy to restore SR in atrial dysrhythmias in infants and small children. 2. Materials and methods This prospective observational study was undertaken at the Royal Children’s Hospital, Melbourne which is a stand-alone 250- bed tertiary referral paediatric hospital serving a population of  A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2010.04.028. ∗ Corresponding author. Tel.: +61 3 9345 5221; fax: +61 3 9345 5506. E-mail address: james.tibballs@rch.org.au (J. Tibballs). approximately 6 million of whom 1.5 million are children aged 16 years or less. It has a full range of clinical services including pae- diatric cardiology and cardiac surgery with an extracorporeal life support programme. Details of the application of DC shock were recorded contem- poraneously and included age and weight (kg) of the patient, pre-shock and post-shock rhythm, energy selected, whether exter- nal pads or paddles or internal paddles were used, position of pads or paddles (anterior-lateral, anterior-posterior positions) and whether synchronization was used. The ECG-defibrillators were all Philips HeartStart XL or MRx Biphasic Defibrillator/Monitors. The former has selectable energies of 2, 3, 5, 7, 10, 20, 30, 50, 70, 100, 150 and 200 joules while those of the latter are 1–10, 15, 20, 30, 50, 70, 100, 120, 150, 170 and 200 joules. These machines have data record- ing cards accessible with a software programme (Philips healthcare, Andover, MA, USA) which enables review of rhythms and param- eters of DC shock including actual energy delivered, impedance, current and use of synchronization. Available were adhesive pads with conductive surface area of 32 cm 2 for patients ≤10 kg and of 102 cm 2 for adults, and paddles of surface area approximately 20 cm 2 for patients ≤10 kg and 80 cm 2 for adults. Defibrillator- monitor machines are maintained in the paediatric intensive care unit (PICU), operating theatres (OT), cardiac catheter laboratory 0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2010.04.028